Ulnar-sided wrist pain: causes and treatment

The wrist is a complex joint, and the little-finger side, called the ulnar side, contains ligaments, cartilage and tendons that stabilise it. The triangular fibrocartilage complex (TFCC) is a group of structures including ligaments and cartilage that connect the two forearm bones and the wrist joint.

Gloucestershire Hospitals says the TFCC is one of the main stabilisers of the wrist, particularly in twisting movements, and that it transmits around 20% of the forces applied to the wrist across to the forearm and acts as a shock absorber. St George's describes it as a wrist stabiliser on the ulnar side.

This page concentrates on the TFCC because it is the cause described in the NHS trust information read for it. Other structures can also produce ulnar-sided pain, so a proper examination matters.

Gloucestershire Hospitals separates two kinds of TFCC problem. In a traumatic injury the attachments or the substance of the TFCC are disrupted, either alone or with a wider wrist injury such as a broken distal radius. Isolated injuries often follow a fall with a significant twist to the wrist, but can also happen when forcibly twisting the wrist with high torque, such as a power drill jamming or hitting a golf ball awkwardly.

St George's adds that the TFCC is commonly injured when the wrist is forced sideways and sometimes through overuse. Degenerative problems are different. They are not injuries but part of ageing, and Gloucestershire says the fibrocartilage disc often perforates in the middle with age because of pressure from the ulnar head. This is common and usually produces no symptoms.

Gloucestershire Hospitals says the most common symptoms of a TFCC injury are pain and swelling over the ulnar side of the wrist and difficulty rotating the forearm. Occasionally there is clicking or snapping on rotation, and very occasionally the wrist jams and will not rotate.

St George's says pain is localised to the outside of the wrist and may worsen with weight-bearing, gripping or moving the wrist, with clicking at the wrist. Everyday jobs such as turning a key, opening a jar or pushing up from a chair can be the ones that hurt.

• Pain over the little-finger side of the wrist, often worse with gripping or twisting.

• Swelling on the ulnar side.

• Clicking, snapping or a catching feeling when you turn the forearm.

• Weakness or a feeling of instability in the wrist.

Gloucestershire Hospitals says the diagnosis is usually made provisionally from the history and examination. The examination centres on whether two joints around the wrist, the distal radio-ulnar joint and the ulnar-carpal joint, are stable under force.

A plain X-ray shows associated bone injury and helps judge stability. An MRI scan usually picks up a significant TFCC tear, and occasionally wrist arthroscopy, a keyhole look inside the joint, is recommended. St George's says formal assessment of the wrist should be completed to determine appropriate management.

Gloucestershire Hospitals says that for most stable injuries the wrist is immobilised in a splint or cast for pain relief while the body heals. Healing takes around 3 months and it is often 6 to 12 months before normal function is regained. Plymouth Hospitals' leaflet on wrist soft tissue injuries advises protecting the wrist for the first few days, elevating it, using compression if needed, then loading it as soon as you feel able, with movement and strengthening exercises.

With an unstable injury the aim is to convert it into a stable one so it heals in the right position, which usually means surgery. The TFCC is reattached to bone with strong sutures and a small anchor. St George's says hand therapy usually sees people after surgery to splint and rehabilitate the wrist.

Once a degenerative problem is diagnosed, Gloucestershire Hospitals says conservative management is the usual recommendation. A wrist splint may help, and a tubigrip support bandage sometimes does. Pain settles with time, though for some people this can take up to two years.

The trust does not recommend regular painkillers for this problem, noting that all painkillers carry a small risk if taken regularly and few patients find them useful. Steroid injections can relieve pain from a degenerative tear but the effect is often short lived. Surgery is an option only where there is a clear underlying structural problem.

Gloucestershire Hospitals says the vast majority of stable TFCC tears heal with time, using scar tissue that takes around 18 months to mature. The wrist may look slightly different on the injured side, which is normal after this injury.

After surgery for an unstable injury the outcome is generally good, but the trust notes few people think their wrist is completely normal afterwards, usually because rotation is limited or the wrist feels weaker. Plymouth's leaflet says most soft tissue injuries heal within 6 to 12 weeks, which is a useful contrast with the longer course of a TFCC tear.

Wrist pain is usually first assessed by a GP, physiotherapist or urgent treatment centre. Persistent ulnar-sided pain is referred to a hand or orthopaedic clinic, with hand therapists providing splinting and exercise programmes.

A private hand surgeon can offer faster MRI and specialist assessment. Ask whether the joint is stable, what the evidence is for the proposed treatment, and how long rehabilitation will last.